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Unboosted Atazanavir for Treatment of HIV Infection

Rationale and Recommendations for Use

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Abstract

Atazanavir (Reyataz®) is a protease inhibitor (PI) for the treatment of HIV infection. Several trials have demonstrated the good efficacy and toxicity profile of atazanavir boosted by ritonavir (atazanavir/r). However, several toxicity events and pharmacokinetic issues due to drug-to-drug interactions (partly related to ritonavir) may complicate atazanavir/r therapy. This is why regimens with unboosted atazanavir have been experimented with and are used in clinical practice. The aim of this article is to identify the clinical settings in which unboosted atazanavir may be a safe and effective option for the long-term control of HIV replication.

Despite the fact that a favourable lipid profile and good gastrointestinal tolerability have been reported in comparative trials, unboosted atazanavir should not be considered an optimal choice for treatment-naive patients. In fact, boosting with ritonavir produces higher atazanavir plasma levels, which are beneficial in terms of efficacy, especially in untreated patients with high plasma HIV RNA.

Clinical data indicate that, in patients with sustained undetectable HIV RNA and without previous virological failure or HIV drug resistance-associated mutations, a switch to unboosted atazanavir-based regimens is a feasible option to control and prevent toxicity events, especially in patients who cannot tolerate ritonavir and in those with severe hyperbilirubinaemia on atazanavir/r. Moreover, while unboosted atazanavir must not be used in pregnant women, it is a recommended option in special populations, such as patients with moderate liver insufficiency. Lastly, unboosted atazanavir in combination with raltegravir may allow the construction of a well tolerated and effective regimen without nucleoside reverse transcriptase inhibitors in patients for whom these drugs are contraindicated.

In conclusion, there is a good rationale, significant clinical interest and accumulating clinical experience with unboosted atazanavir-based regimens, although this formulation should be used only in specific situations and as a maintenance strategy. Moreover, therapeutic drug monitoring could be useful in specific circumstances (such as in patients with liver impairment or in case of potential drug-drug interactions).

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Acknowledgements

No sources of funding were used to conduct this study or prepare this manuscript. The authors have no conflicts of interest that are directly relevant to the content of this article.

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Authors and Affiliations

  1. Department for Infectious and Tropical Diseases, Institute for Infectious and Tropical Diseases, University of Brescia, School of Medicine, P.le Spedali Civili, 1, 25123, Brescia, Italy

    Emanuele Focà, Davide Motta &  Carlo Torti MD

  2. Department of Infectious Diseases, Ospedali Riuniti, Bergamo, Italy

    Diego Ripamonti

  3. Unit of Infectious Diseases, “Magna Graecia” University, Catanzaro, Italy

    Carlo Torti MD

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  1. Emanuele Focà
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  2. Diego Ripamonti
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  3. Davide Motta
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  4. Carlo Torti MD
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Correspondence to Carlo Torti MD.

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Focà, E., Ripamonti, D., Motta, D. et al. Unboosted Atazanavir for Treatment of HIV Infection. Drugs 72, 1161–1173 (2012). https://doi.org/10.2165/11631070-000000000-00000

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